On September 9, the House Energy and Commerce Subcommittee on Health held a hearing examining a draft bill (as-yet-unnumbered) to extend the Ryan White Comprehensive AIDS Resources Emergency (CARE) Act (P.L. 109-415) through FY2012; the current authorization expires September 30, 2009.
The draft legislation would authorize “such sums as may be necessary” for FY2010-2013; in FY2009 the program was authorized at $2.32 billion, including $72 million for Part D, “Services for Women, Infants, Youth, Children, and their Families.” In FY2010, the program would receive $2.292 billion, including $78.728 million for Part D under the House-passed bill (see The Source, 7/24/09). Under the Senate-passed bill, the program would receive $2.273 billion in FY2010, including $76.845 million for services for women and their families (see The Source, 8/7/09).
Part D grantees are required to provide medical care to clients, either directly or by contract. However, some Part D clients are eligible for services under Medicaid or the State Children’s Health Insurance Program (SCHIP). The draft bill would maintain the overall responsibilities and requirements for Part D grantees, but would “clarify” that Part D should be the “payer of last resort” for clinical services for clients who are otherwise eligible under Medicaid or SCHIP.
Under current law, states may submit code-based HIV data directly to the Health Resources and Services Administration (HRSA). However, code-based data is less reliable than the more accurate name-based system, as it tends to be more duplicative when counting people with HIV/AIDS. In addition, states that use code-based counting are subject to a five percent cap on increases in their case count. As eight large states (CA, HI, IL, MD, MA, OR, RI, VT, and DC) do not have named-based reporting fully in place, the draft bill would allow them until 2013 to change their systems, subject to the penalties described above.
The draft bill also would continue the “hold harmless” provisions in the 2006 reauthorization for Emergency Metropolitan Areas (EMAs) (areas with at least 50,000 people and at least 2,000 AIDS cases reported in the prior five years) and Transitional Grant Areas (TGAs) (areas with at least 1,000 people, but fewer than 2,000 cumulative AIDS cases during the prior five calendar years). Under the bill, grants for FY2010 would be set at 95 percent or more of FY2009 funding, and FY2011 and 2012 would be equal to or greater than FY2010 funding.
Finally, the draft legislation would require the Government Accountability Office (GAO) to “periodically” report on barriers to HIV program integration, particularly for racial and ethnic minorities; current law requires a report every two years.
GAO Health Care Director Marcia Crosse testified about the effects of the 2006 law, which placed a 10 percent cap on administrative expenses under Part D. “For our review of grantees’ experiences under the Part D administrative expense cap, we surveyed all 90 Part D grantees, collecting information and opinions about the administrative expense cap for FY2007, the first year the administrative cap was in effect…The majority of the 83 grantees that responded to our survey reported that the cap had not affected the services they provide. However, four grantees reported increasing services and three grantees reported reducing client services in response to the cap. In addition, the majority of the grantees also reported that the cap has had a negative effect on their Part D program, even if it has not changed client services, because it has, for example, made it necessary for clinical staff to perform administrative tasks.”
Mary K. Wakefield, HRSA administrator, generally praised the draft legislation, saying that a prompt reauthorization would “minimize disruption of funding and services for grantees and clients.” However, she said the current distinction between EMAs and TGAs should be eliminated: “Under the current statute, 75 percent of Part A funding is allocated to EMAs and the remaining 25 percent is distributed to TGAs. Although EMAs have a higher disease burden as compared with TGAs, the TGAs receive more funding per client…HRSA proposes designating Part A grantees as EMAs when those grantees have greater than or equal to 1,000 cases of AIDS during the most recent period of five calendar years for which such data are available. By eliminating the EMA/TGA distinction, the appropriation for Part A could be distributed proportionally across all highly impacted jurisdictions based on the number of living HIV/AIDS cases.” Part A allocates grants to areas severely affected by HIV/AIDS. Seventy-five percent of the grant award must be used for “core services,” such as prescription drug assistance, early intervention services, hospice care, and mental health services; the remaining 25 percent may be used to provide “supportive services,” such as outreach, medical transportation, linguistic services, and respite for caregivers.
Julie Scofield, executive director of the National Alliance of State and Territorial AIDS Directors, and Dr. Donna E. Sweet, professor at the University of Kansas School of Medicine, also testified.